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06/2022 cmc DNR Form 542-0960 Instructions INSTRUCTIONS FOR COMPLETING GROUNDWATER HAZARD STATEMENT Unless exempt as detailed in paragraph 8, below, the transferor of real property is required to complete this form. The purpose of the statement is to satisfy legal requirements for filing instruments of conveyance of real property with the county recorder (Iowa Code Section 558.69). The Department of Natural Resources does not approve or disapprove of property transfers based on these statements. If one of the conditions described below is present on the property, the statement must be signed by one of the persons transferring the property interest or that person’s agent. An agent signing this form represents the information from transferor to be correct. If none of the conditions described below are located on the property, the deed must include the statutory language in paragraph 8, below. For the most part the information requested is clear (name, address, etc.). One statement under each of the numbered items 2, 3, 4, 5, and 6) must be checked, and if one or more of the statements checked requires the transferor to provide additional information, that information is to be provided on a separate sheet. Relate the additional information to the specific category of facility (well, etc.) by numbering it with the corresponding number 2, 3, 4, 5, and When describing the location of a facility on the property, be reasonably precise, such as a specific distance and general direction from a landmark or corner of the property. A professional survey is not necessary. The following definitions are for use in completing the form. 1. Wells - A “well” is any excavation that is drilled, cored, bored, augered, washed, driven, dug, jetted or otherwise constructed for the purpose of exploring for groundwater, monitoring groundwater, utilizing the geothermal properties of the ground, or extracting water from or injecting water into the aquifer, and includes abandoned wells. “Well” does not include an open ditch or drainage tiles which discharge to the surface. If a well is present, provide the type, location, and status. For purposes of the groundwater hazard statement, the types of wells are agricultural drainage wells, public water supply wells, closed loop geothermal systems, monitoring wells, and other private water wells. You may further describe the well’s purpose, if warranted. Describe the location as a distance in feet and cardinal direction from the building, home, garage, or other permanent structure. GPS coordinates may be provided in addition to the description described previously. Well status includes active, standby, or abandoned. An “active well” is a well that is currently in use. An “abandoned well” is a well no longer in use or in such state of disrepair that continued use is unsafe or impracticable. Abandoned wells are to be properly plugged in accordance with chapter 39 of the rules of the Department of Natural Resources. (567 Iowa Administrative Code, Chapter 39). A “standby well” means a water well which is temporarily taken out of service with the expectation of being returned to service at a future date. An “agricultural drainage well” is a well constructed for the purpose of draining, or which drains, water from agricultural land to an aquifer (underground), excluding drainage tile intakes which outlet to the surface. Agricultural drainage wells are required to be registered with the department by September 30, 1988, and the owner of the well and of the land drained by the well are to develop a plan, proposing alternatives to the use of the well by July 1, 1998 2. Solid Waste - “Solid waste” means garbage, refuse, rubbish and other similar discarded solid or semisolid material. It does not include dirt, stone, brick, or similar inorganic material used for fill, as long as no other solid waste is included. See 567 Iowa Administrative Code 100.2 (455B) for further definitions. A “disposal site” is any area on the property on, in, or under which solid waste has been disposed, whether or not the disposal is or was regulated by the department. If the transferor or agent has not received notice from the Department of Natural Resources that the disposal site has been deemed to be potentially hazardous, there is no duty to inquire to the department. *Note The land application of sludges or soils resulting from the remediation of underground storage tank releases accomplished in compliance with Department of Natural Resources rules without a permit is not required to be ---PAGE BREAK--- 06/2022 cmc DNR Form 542-0960 Instructions reported as the disposal of solid waste or hazardous waste. (See Iowa Code section 558.69) Information in regard to a solid waste disposal site shall be included in Attachment 3. Hazardous Wastes - “Hazardous waste” is defined in Iowa Code section 455B.411, 567 Iowa Administrative Code 141.2 (455B), and federal regulations referenced therein. It is generally defined as waste that poses a threat to human health or the environment. It includes wastes which are ignitable, corrosive, toxic, explosive, violently reactive, or specifically listed as hazardous in the Code of Federal Regulations (40 CFR 261). EXCLUDED are household wastes, agricultural wastes returned to the soil as fertilizers or soil conditioners, agricultural chemicals applied or disposed of by a farmer in accordance with the manufacturer’s instructions, triple-rinsed agricultural chemical containers disposed of by farmers (where the rinsate is used as makeup water in the tankmix and applied at appropriate rates), and other specific materials. Persons are legally required to be aware of hazardous waste laws. Information in regard to a solid waste disposal site shall be included in Attachment 4. Underground Storage Tanks - “Underground storage tank” means one or a combination of tanks, including underground piping connected to the tanks, used to contain an accumulation of regulated substances, and the volume of which is 10 percent or more beneath the surface of the ground. “Regulated substances” include petroleum products and hazardous or toxic materials identified in 567 Iowa Administrative Code 135.2 (455B). Underground storage tank does not include: a. Farm or residential tanks of 1,100 gallons or less capacity used for storing motor fuel for noncommercial purposes. But See 455B.473(4)) b. Tanks used for storing heating oil for consumptive use on the premises where stored. c. Residential septic tanks. d. Pipeline facilities regulated by state or federal law. e. A surface impoundment, pit pond, or lagoon. f. A storm water or wastewater collection system. g. A flow-through process tank. h. A liquid trap or associated gathering lines directly related to oil or gas production and gathering operations. i. A tank in an underground area such as a basement or mine, if the tank is on or above the surface of the floor. j. Pipes connected to the above exclusions. “Tank type” means the material of construction (steel, fiberglass reinforced plastic [FRP], or other [specify]), and any internal or external protection such as a protective coating or wrapping, or cathodic protection. 5. Private Burial Sites - “Private Burial Site” means one or more graves containing human remains. For each site the transferor shall state the location of the site. For each decedent buried on the property the transferor shall state all known identifying information of that decedent including name, date of death, and date of birth. 6. Private Sewage Disposal System - “Private Sewage Disposal System” means a system which provides for the treatment or disposal of domestic sewage from four or fewer dwelling units or the equivalent of less than 16 individuals on a continuing basis, including domestic waste, whether residential or nonresidential, but not including industrial waste of any flow rate except as provided for in 567 Iowa Administrative Code 68.11(455B). “Private sewage disposal system” includes, but is not limited to, septic tanks, holding tanks for waste, chemical toilets, impervious vault toilets and portable toilets. Beginning July 1, 2009, prior to any transfer of ownership of a building where a person resides, congregates, or is employed that is served by a private sewage disposal system, the sewage disposal system serving the building shall be inspected. In the event that weather or other temporary physical conditions prevent the certified inspection from being conducted, the buyer shall execute and submit a binding acknowledgment with the county board of health to conduct a certified inspection of the private sewage disposal system at the earliest practicable time and to be responsible for any required modifications to the private sewage disposal system as identified by the certified ---PAGE BREAK--- 06/2022 cmc DNR Form 542-0960 Instructions inspection. For the purposes of this subsection, “transfer” means the transfer or conveyance by sale, exchange, real estate contract, or any other method by which real estate and improvements are purchased, if the property includes at least one but not more than four dwelling units. The full list of time of transfer exemptions can be found in Iowa Code section 455B.172(11)(a) and 567 Iowa Administrative Code 69.2(1)”a” (455B). Note that these exemptions are different from the declaration of value exemptions and the exemption from filing described in paragraph 8, below. 7. Filing - This form must be presented to the county recorder when the document to be recorded is filed. The Recorder shall forward the original to the transferee when the recorded instrument is returned. The recorder is not required to keep any copies. 8. Exemption from filing - After July 1, 2022, and pursuant to Iowa Code section 558.69(8A), if none of the conditions described in paragraphs 1-6 are present on the property, the seller must record the following language on the first page of the deed, instrument, or other writing instead of recording the groundwater hazard statement: “There is no known private burial site, well, solid waste disposal site, underground storage tank, hazardous waste, or private sewage disposal system on the property as described in Iowa Code section 558.69, and therefore the transaction is exempt from the requirement to submit a groundwater hazard statement.” Pursuant to Iowa Code section 558.69(8B)(a), a county recorder cannot record deed unless the deed contains the language above or if a groundwater hazard statement is filed with the declaration of value. Please consult your realtor or legal counsel for further advice on this exemption. Pursuant to Iowa Code section 558.69(8A)(b), the owner of the property is responsible for the accuracy of this statement, and the Department provides this information for statutory reference only.